International Orthopedics: Women’s Work

While they didn’t go to climb Mount Everest, some say that the trip to Nepal was the high point of their careers. The women of WOGO—Women Orthopaedist Global Outreach—have been planting their flag around the world since 2006, helping women to overcome joint disease and disability, and to live more fulfilling lives.

Dr. Audrey Tsao, a total joint surgeon in private practice at the Sun Valley Orthopaedic Surgeons in Arizona, states, “Several of the female orthopedic surgeons met while working on a Zimmer design team. We—Drs. Jennifer Cook, Robyn Hakanson, Rinelda Horton and myself—developed a bond, and soon decided that we wanted to reach out to women in need around the world. WOGO was born, and then developed into an Operation Walk team with the addition of Dr. Amanda Marshall and on this inaugural trip, Dr. Debra Thomas”

Building on a foundation, WOGO members took the advice of those at Operation Walk and set their sights on Nepal. Dr. Tsao: “We chose Nepal in part because it is considered to be ‘female friendly, ’ meaning we would hopefully encounter fewer cultural or professional barriers than in other countries. Also, Operation Walk had done a trip there in 2005, and had established some relationships that we could build upon.”

The WOGO team landed in Kathmandu in September 2010 at the end of the rainy season—which meant that they were starting their work in particularly hot, humid circumstances. Dr. Tsao recalls, “The reality is that there were no flush toilets at the hospital, and that the electricity was barely more than a mass of dangling wires. These conditions were ‘muted out, ’ however, by the incredible warmth of the people, and their extraordinary determination to get well."

I was in awe of the Nepalese patients; even individuals with severe arthritis deformities used very little pain medication. They would walk with what we would consider a ‘non walkable’ knee and were, in general, back on their feet and doing two flights of stairs a couple of days after surgery. There were no excuses and no complaints.

Even in a resource-limited environment, both patients and surgeons were creating an atmosphere of excellence. Dr. Tsao says, “The sites were carefully screened to ensure that we would have enough patients to treat as well as three or four dedicated ORs. We brought all of our own personnel and equipment, including supplies for anesthesia, sterilization, medications, etc. People ended up traveling from nearly all parts of the country. We were able to perform 44 total knee replacements in three and a half days; we then rounded on patients for several days in the morning and evening so that we could ensure it was safe for them to go home.”

Not satisfied with the “swoop in and save” strategy, the surgeons of WOGO brought knowledge so that—eventually—their input won’t be needed. “Many Nepalese surgeons, nurses, and students observed the surgeries, and several surgical residents scrubbed in (depending on the procedure). We transferred as much knowledge as possible during those times, but also addressed the issue of physical therapy (PT). While they had some staff familiar with PT, such postop care was really a luxury. We taught the nurses about PT, as well as the patients and the family members. It was astounding and heartening to see the contribution that the families made to patient care. It was the family who brought the patients food, transported them, changed their dressings, etc.”

Although one of Dr. Tsao’s most vivid memories was being chased by livestock (!), her most important memories are likely those that involve passing on knowledge to her Nepalese peers. “We held a day long seminar on primary total knee replacement where we discussed indications for surgery, surgical techniques, complications, and postoperative care. Most participants had some experience with these surgeries, but we were able to widen their knowledge base, especially regarding operative techniques. One thing that we couldn’t help with is the ongoing access to care."

Some patients travel several days to reach the hospital, something that really becomes an issue if that person has to return to the hospital for a complication such as wound drainage. Even now—via email or text messaging—we are continuing to help our Nepalese colleagues with this as far as digging down into what is truly a problem requiring hospital treatment and what the patient can handle at home with the help of family.

Part of the WOGO goal was to have as wide of an impact on young Nepalese females as possible. “Several of our team members went to a girl’s school and spent time speaking with the students about life choices, careers, and practical steps towards their dreams. We were pleased to be able to serve as examples of what is possible for women.”

Thinking ahead by looking back, Dr. Tsao states, “While we were well equipped and organized, the next time we make such a trip I would make some adjustments to our equipment. For example, we naturally feel safe using the anesthetic machines that are found in our hospitals in the U.S. Abroad, however, we decided to use spinal anesthesia because on-site equipment was not as up to date. Also, I would prefer to bring our own portable sterilizer. As it was, if someone dropped something on the floor that was it for 24 hours. Our Nepalese colleagues did invite us back, and we hope to be able to return in the not too distant future.”

Dr. Rinelda Horton, an orthopedist with Kaiser Permanente Mid-Atlantic Medical Group in Maryland, also did her best to provide training and inspiration to those on the other side of the world. A bit of a cultural anthropologist, Dr. Horton says, “When we first arrived I was surprised to find that women seemed to be treated rather like second class citizens. Both on the airplane and at the hotel—not at the hospital—women were jostled around a bit and we had to ‘fight’ our way off the elevator. Staff, patients, and families we encountered at the hospital displayed no such behavior, however. But the reality for women in Nepal is that there is a greater need for joint replacement, but they are not first on the list for surgery because of their place in society.”

Anyone on the list, male or female, could be waiting awhile, says Dr. Horton. “I did not get the impression that most orthopedists in the country were doing joint replacements. Even if they were, they were not using the newest techniques. For example, with hip replacements we in the U.S. use porous implants that allow the bone to grow into the prosthesis, while in Nepal they still use cement routinely. We brought the newest implants that are available today in the U.S., with Zimmer donating the Flex knee and the Gender Knee. It was frustrating to see someone with a bad deformity who obviously needed a knee replacement, but because the deformity was so severe it would require revision implants that include augments and stems. Shipping was so expensive that we only had one revision set available, which was reserved for emergencies or in case there were any intraoperative complications.”

“There were some patients who really needed an operation, but because of the complexity of the surgery and the lack of revision implants available we were unable to perform their surgery. In these cases, we tried to get braces sent over, so at least they would have some support. For revisions and complex primary joints there are so many trays that have to be shipped in just for one case. Therefore, we just focused on routine cases that wouldn’t need revision implants. By doing the more routine cases we were able to help more patients. Early on we had to decide whether to help one patient by doing the revision or many patients by doing the more routine cases. We felt it was better to help more patients and thus have a greater impact.”

It was a revitalized and appreciative Dr. Rinelda Horton who returned to Maryland after the trip. “My cases here in the U.S. seemed rather easy upon my return. In Nepal, the batteries went out the first day and there were times when we had no suction. Many times we had to substitute things. For example, we reused OrthoWrap sheets to hold a leg; we also repeatedly reused pop-off sutures. Additionally, since we didn’t have a routine bone hook we had to take another instrument—an ‘Army Navy’—something normally used for retracting tissue—and use it like a bone hook. In the end, it all worked out.”

The surgeons, both those in Nepal and those visiting from WOGO, know that sterility is an ongoing issue. Dr. Horton notes, “Some issues are that many people in the hospital are wearing flip flops and that patients are required to bring their own blankets. Because of this and other sterility problems, patients tend to be on antibiotics longer in Nepal than in the U.S. Another important issue that we would like to help out with is the expense of preoperative testing (something the patients must pay for). It seemed that many people who needed surgery were not able to go through with it because they could not afford this testing.”

Dr. Horton concludes, “We were very privileged to become part of the Nepali world, if only for a short period of time. Hopefully, we left a positive footprint or two.”

For more information on Women Orthopaedist Global Outreach, please visit http://www.wogo.org/